1. Cleft lip and palate is a congenital defect caused by the failure of fusion between embryonic processes during lip and palate development.
2. It has a multifactorial etiology including both genetic and environmental factors. The exact cause is often unknown.
3. Cleft lip and palate occurs in about 1 to 2 per 1000 births globally, with varying prevalence across ethnic groups. Classification systems describe the location and extent of the cleft.
This document provides an overview of Lefort I osteotomy, including:
- A brief history describing the development of maxillary osteotomy techniques.
- Anatomical considerations and the biologic basis for maxillary osteotomies, which have shown adequate blood supply can be maintained.
- Indications for Lefort I osteotomy include altering vertical dimension, anteroposterior movements, and surgical expansion of the maxilla.
- Types of Lefort I osteotomies are described, including classic, quadrangular, and segmental variations. Postoperative management and potential complications are also outlined.
This document discusses the comprehensive management of cleft lip and palate. It covers the embryology, anatomy, classification, rationale and various techniques for cleft palate repair including Von Langenbeck, Bardach, Furlow and Delaire techniques. It also discusses velopharyngeal insufficiency, its assessment and various surgical techniques for correction including palatal lengthening and pharyngeal flaps. The complications of cleft lip and palate surgeries are discussed along with their management. The document provides a detailed overview of cleft palate and its multidisciplinary management.
This document discusses the history and types of flaps used in reconstructive surgery. It begins by defining a flap as a unit of tissue transferred from a donor site to a recipient site while maintaining its own blood supply. It then discusses the origins of flaps dating back to 600 BC and highlights some important developments over time, including the first use of forehead and cheek flaps for nasal reconstruction. The document outlines different ways flaps can be classified, such as by blood supply, location, tissue content, configuration, and transfer method. Specific flap types are defined, such as advancement, rotational, and interpolated flaps. Key considerations for flap design like tension lines and esthetic zones are also reviewed.
The document discusses alveolar bone grafting techniques for treating cleft lip and palate. It provides background on the goals and timing of secondary alveolar bone grafting between ages 8-12 years to provide bony support for tooth eruption and closure of oronasal fistulas. A study reviewed outcomes of bone grafting in 19 patients and found most cleft canine teeth continued root development and erupted normally, while 4% were impacted. Grafting successfully closed anterior fistulas in all cases.
This document provides an overview of secondary alveolar bone grafting for cleft lip and palate patients. It discusses the goals and optimal timing of the procedure, how patients are evaluated, and details regarding graft source options including iliac crest, tibia, rib, and cranial bone. It also covers pre-surgical orthodontics and preparation of the cleft alveolus, as well as post-operative care considerations.
This document discusses classifications and repair techniques for cleft palate. It describes three main groups of cleft palate classifications based on the location and extent of the cleft. For repair, it recommends timing of 12-18 months when babbling occurs. Key principles of repair include closure of the defect, reconstruction of the muscle sling, and retropositioning of the soft palate. Several surgical techniques are outlined, including von Langenbeck's, Veau-Wardill-Kilner, Bardach's two-flap, and Furlow Double Opposing Z-Plasty methods. Post-operative care and potential complications are also reviewed.
This document discusses alveolar cleft bone grafting. It begins with an introduction to cleft lip and palate treatment and the importance of alveolar bone grafting. It then covers the history, timing, rationale, and techniques of alveolar bone grafting. Key points include that secondary bone grafting between ages 6-13 is most common, with the goal of providing stability for dental arch development and closure of oronasal fistula. The document discusses various graft materials and surgical techniques to achieve tension-free closure of the alveolar cleft.
1. Cleft lip and palate is a congenital defect caused by the failure of fusion between embryonic processes during lip and palate development.
2. It has a multifactorial etiology including both genetic and environmental factors. The exact cause is often unknown.
3. Cleft lip and palate occurs in about 1 to 2 per 1000 births globally, with varying prevalence across ethnic groups. Classification systems describe the location and extent of the cleft.
This document provides an overview of Lefort I osteotomy, including:
- A brief history describing the development of maxillary osteotomy techniques.
- Anatomical considerations and the biologic basis for maxillary osteotomies, which have shown adequate blood supply can be maintained.
- Indications for Lefort I osteotomy include altering vertical dimension, anteroposterior movements, and surgical expansion of the maxilla.
- Types of Lefort I osteotomies are described, including classic, quadrangular, and segmental variations. Postoperative management and potential complications are also outlined.
This document discusses the comprehensive management of cleft lip and palate. It covers the embryology, anatomy, classification, rationale and various techniques for cleft palate repair including Von Langenbeck, Bardach, Furlow and Delaire techniques. It also discusses velopharyngeal insufficiency, its assessment and various surgical techniques for correction including palatal lengthening and pharyngeal flaps. The complications of cleft lip and palate surgeries are discussed along with their management. The document provides a detailed overview of cleft palate and its multidisciplinary management.
This document discusses the history and types of flaps used in reconstructive surgery. It begins by defining a flap as a unit of tissue transferred from a donor site to a recipient site while maintaining its own blood supply. It then discusses the origins of flaps dating back to 600 BC and highlights some important developments over time, including the first use of forehead and cheek flaps for nasal reconstruction. The document outlines different ways flaps can be classified, such as by blood supply, location, tissue content, configuration, and transfer method. Specific flap types are defined, such as advancement, rotational, and interpolated flaps. Key considerations for flap design like tension lines and esthetic zones are also reviewed.
The document discusses alveolar bone grafting techniques for treating cleft lip and palate. It provides background on the goals and timing of secondary alveolar bone grafting between ages 8-12 years to provide bony support for tooth eruption and closure of oronasal fistulas. A study reviewed outcomes of bone grafting in 19 patients and found most cleft canine teeth continued root development and erupted normally, while 4% were impacted. Grafting successfully closed anterior fistulas in all cases.
This document provides an overview of secondary alveolar bone grafting for cleft lip and palate patients. It discusses the goals and optimal timing of the procedure, how patients are evaluated, and details regarding graft source options including iliac crest, tibia, rib, and cranial bone. It also covers pre-surgical orthodontics and preparation of the cleft alveolus, as well as post-operative care considerations.
This document discusses classifications and repair techniques for cleft palate. It describes three main groups of cleft palate classifications based on the location and extent of the cleft. For repair, it recommends timing of 12-18 months when babbling occurs. Key principles of repair include closure of the defect, reconstruction of the muscle sling, and retropositioning of the soft palate. Several surgical techniques are outlined, including von Langenbeck's, Veau-Wardill-Kilner, Bardach's two-flap, and Furlow Double Opposing Z-Plasty methods. Post-operative care and potential complications are also reviewed.
This document discusses alveolar cleft bone grafting. It begins with an introduction to cleft lip and palate treatment and the importance of alveolar bone grafting. It then covers the history, timing, rationale, and techniques of alveolar bone grafting. Key points include that secondary bone grafting between ages 6-13 is most common, with the goal of providing stability for dental arch development and closure of oronasal fistula. The document discusses various graft materials and surgical techniques to achieve tension-free closure of the alveolar cleft.
This document outlines orthognathic surgery procedures. It discusses diagnosis and planning, including indications, contraindications, and special considerations. Presurgical orthodontics including decompensation and arch coordination are described. Surgical techniques for the maxilla include LeFort I, II, III osteotomies and segmental procedures. For the mandible, procedures include sagittal split and vertical subsigmoid osteotomies. Splint fabrication and post-surgical care are also covered.
This document discusses cleft rhinoplasty, including the history, relevant anatomy, types of cleft nose deformities, and approaches to treatment. It notes that cleft nose deformities can cause cosmetic and breathing problems. Treatment involves primary rhinoplasty at the time of lip repair to alter the nose, followed by secondary rhinoplasty after facial growth is complete. Presurgical nasoalveolar molding may be used to improve nasal symmetry before primary rhinoplasty. The goal of cleft rhinoplasty procedures is to correct the nasal deformity in stages as the patient ages.
This document provides information on lip and cheek reconstruction techniques. It begins with an overview of lip anatomy including muscles, innervation, and vascular supply. It then discusses various reconstruction approaches for both the upper and lower lip depending on the size and location of the defect. Techniques described include primary closure, local flaps such as Abbe and Estlander flaps, and free flaps for larger defects involving over 2/3 of the lip. The goal of reconstruction is to provide skin cover, recreate the vermilion border, maintain adequate oral competence, and optimize cosmetic and functional outcomes.
Condylar sag is defined as an immediate or late change in the position of the condyle in the glenoid fossa after orthognathic surgery, leading to an undesirable change in occlusion. It can occur after procedures like BSSO, IVRO, and Lefort I osteotomy. Risk factors include incorrect vectoring during condylar positioning and incomplete bone splits. Condylar sag is classified as central or peripheral, and can be diagnosed intraoperatively by examining changes in occlusion. Preventative measures include rigid fixation and intraoperative patient awakening to detect changes.
This document provides an overview of genioplasty procedures. It begins with an introduction to genioplasty and anatomy. It then discusses preoperative evaluation including facial analysis, cephalometric evaluation, and chin classifications. Next, it covers various techniques for correcting chin deformities including osseous genioplasty procedures like horizontal osteotomy with advancement or reduction, and alloplastic genioplasty. It concludes with a brief discussion of complications. The document provides detailed information on evaluating patients, planning procedures, and technical aspects of different genioplasty techniques.
This document discusses the use of tongue flaps in reconstructive surgery. It provides a brief history of tongue flaps dating back to 1909. Various types of tongue flaps are described, including posterior based dorsal flaps, anterior based dorsal flaps, transverse dorsal tongue flaps, perimeter flaps, and dorsoventral flaps. Indications for tongue flaps include moderate sized oral defects, defects exposing bone, and repairs after cancer resections. Four case studies are presented demonstrating the use of different tongue flap techniques for reconstructing posterior palatal, maxillary, and anterior palatal defects. Tongue flaps are concluded to be a reliable and versatile option for oral reconstruction with over 100 years of successful use and minimal
- The document discusses clinical aspects of cleft lip repair, including epidemiology, embryology, surgical anatomy, classification, management, and future directions.
- Cleft lip is the most common craniofacial malformation, occurring in about 1 in 1,000 live births. The rotation-advancement technique developed by Millard is currently the most commonly used repair method.
- The goals of cleft lip repair are to reconstitute lip competence and symmetry while minimizing scar visibility. Proper postoperative care and follow-up are important to monitor for complications and ensure good healing. Fetal surgery and in utero repair may be future areas of development.
This document discusses algorithms for reconstructing mandibular defects. It begins by classifying mandibular defects according to the AOCMF, Jewer's HCL, and Peter G. Cordeiro systems. Cordeiro's classification addresses both bony and soft tissue defects. The document then outlines algorithms for approaching reconstruction of different defect types, such as anterior, hemimandibular, and lateral defects. A variety of reconstruction options are discussed, including fibula flaps, scapular flaps, and regional flaps. Factors to consider like donor site morbidity and technical complexity are also addressed. The conclusion recommends the vascularized free fibula flap as the gold standard for large mandibular defects.
Chinese physicians were the first to describe cleft lip repair techniques, which initially involved simply excising the cleft margins and suturing them together. Over time, surgical techniques evolved to use local flaps. In the mid-20th century, the triangular flap technique was introduced and popularized as it allowed for tension-free repair of wide clefts. The rotation-advancement technique, described by Millard, is now most commonly used in the US as it is flexible and allows modifications during surgery while approximating a new philtral column. The goals of repair include reconstituting oral competence and symmetry while optimizing nasal function and aesthetics.
The Weber-Fergusson incision is indicated for access to tumors involving the maxilla extending superiorly to the infraorbital nerve and into or involving the orbit. It provides wide access to all areas of the maxilla. The incision line is drawn through the vermillion border along the filtrum of the lip, extending around the base of the nose along the facial nasal groove. It then extends infraorbitally below the cilium to the lateral canthus. Tarsorrhaphy sutures are placed in the eyelid. The incision is made through the skin and subcutaneous tissue along the nose, and the full thickness upper lip is transsected with ligation of the labial artery
This document provides an overview of surgical approaches to the temporomandibular joint (TMJ). It discusses several extraoral and intraoral approaches, including the preauricular, endaural, postauricular, coronal, retromandibular, and intraoral vestibular approaches. For each approach, it highlights considerations for exposure and visibility of the joint, avoidance of neurovascular structures, and postoperative aesthetics. Complications are also briefly mentioned. Detailed anatomical descriptions and illustrations are provided to demonstrate the surgical planning and exposure for different approaches.
This document discusses various surgical approaches to the temporomandibular joint (TMJ). It begins by outlining important anatomical structures in the region, including nerves, arteries and layers of fascia. It then describes several common approaches - preauricular, endaural, postauricular, submandibular, retromandibular and intraoral. For each approach, it provides details on the surgical technique, indications, advantages and disadvantages. References are also provided at the end for further reading on the surgical anatomy of the cervical and mandibular distributions of the facial nerve.
The nasolabial flap is used to reconstruct defects of the nose, lower eyelid, cheek, lip, oral commissure and anterior oral cavity. It has a reliable blood supply from the facial and angular arteries. The flap can be raised in a superior or inferior direction and is outlined along the nasolabial fold. The technique involves raising the flap in a supra-muscular plane and transferring it to the defect site through a transoral tunnel. Advantages are a concealed donor site scar and good color and texture match. Complications include infection, necrosis and asymmetry.
This document provides a 3-part summary of cleft lip and palate repair techniques. It discusses various techniques for unilateral and bilateral cleft lip repair such as Millard's rotation-advancement and Tennison-Randall triangular flap. For cleft palate repair, it describes techniques including Bardach two-flap palatoplasty and Furlow palatoplasty. It also covers topics like velopharyngeal insufficiency, alveolar bone grafting, and the roles of pre- and post-surgical orthodontics.
orthognathic surgery is very intresting and well knowing branch in oral surgery ....this presentation is dealing with jaw correction surgery in upper jaw.
Detailed discussion on diagnosis and management of TMJ ankylosis. Surgical anatomy and applied aspects of TMJ is discussed. Reconstruction of ramus-condyle unit is also discussed. Compications of TMJ surgery are also discussed
Panfacial fractures involve multiple facial bones, including the frontal bones, zygomaticomaxillary complex, naso-orbitoethmoid region, maxilla and mandible. Due to the complex nature of these injuries, management requires careful planning and sequencing of treatment to restore facial functions, features and symmetry. Key goals are to reestablish occlusion, stabilize major facial supports to restore three-dimensional contour, and provide a stable scaffold for soft tissue healing. Proper imaging, surgical approaches and attention to anatomical landmarks are important to achieve accurate reduction and fixation.
This document provides an overview of cleft lip and palate disorders including embryology, classification, incidence, clinical presentation, treatment approaches, and secondary management considerations. It discusses the development of the lip and palate, classifications of cleft types, incidence rates, clinical issues such as feeding and speech difficulties, and surgical techniques for cleft lip repair and cleft palate repair in infants and children. Secondary procedures for dental, hearing, nasal, and orthognathic issues are also outlined.
- Cleft lip and palate is a birth defect where the lip and/or palate do not fully form during development in utero.
- The incidence of cleft lip and palate varies by race, with Asians having the highest rate at 1 in 500 live births. Males are more likely than females to be affected.
- Treatment involves a multidisciplinary approach including surgery to repair the cleft, orthodontics, speech therapy and psychological support. The goal is to achieve normal appearance, speech and dental function.
This document outlines orthognathic surgery procedures. It discusses diagnosis and planning, including indications, contraindications, and special considerations. Presurgical orthodontics including decompensation and arch coordination are described. Surgical techniques for the maxilla include LeFort I, II, III osteotomies and segmental procedures. For the mandible, procedures include sagittal split and vertical subsigmoid osteotomies. Splint fabrication and post-surgical care are also covered.
This document discusses cleft rhinoplasty, including the history, relevant anatomy, types of cleft nose deformities, and approaches to treatment. It notes that cleft nose deformities can cause cosmetic and breathing problems. Treatment involves primary rhinoplasty at the time of lip repair to alter the nose, followed by secondary rhinoplasty after facial growth is complete. Presurgical nasoalveolar molding may be used to improve nasal symmetry before primary rhinoplasty. The goal of cleft rhinoplasty procedures is to correct the nasal deformity in stages as the patient ages.
This document provides information on lip and cheek reconstruction techniques. It begins with an overview of lip anatomy including muscles, innervation, and vascular supply. It then discusses various reconstruction approaches for both the upper and lower lip depending on the size and location of the defect. Techniques described include primary closure, local flaps such as Abbe and Estlander flaps, and free flaps for larger defects involving over 2/3 of the lip. The goal of reconstruction is to provide skin cover, recreate the vermilion border, maintain adequate oral competence, and optimize cosmetic and functional outcomes.
Condylar sag is defined as an immediate or late change in the position of the condyle in the glenoid fossa after orthognathic surgery, leading to an undesirable change in occlusion. It can occur after procedures like BSSO, IVRO, and Lefort I osteotomy. Risk factors include incorrect vectoring during condylar positioning and incomplete bone splits. Condylar sag is classified as central or peripheral, and can be diagnosed intraoperatively by examining changes in occlusion. Preventative measures include rigid fixation and intraoperative patient awakening to detect changes.
This document provides an overview of genioplasty procedures. It begins with an introduction to genioplasty and anatomy. It then discusses preoperative evaluation including facial analysis, cephalometric evaluation, and chin classifications. Next, it covers various techniques for correcting chin deformities including osseous genioplasty procedures like horizontal osteotomy with advancement or reduction, and alloplastic genioplasty. It concludes with a brief discussion of complications. The document provides detailed information on evaluating patients, planning procedures, and technical aspects of different genioplasty techniques.
This document discusses the use of tongue flaps in reconstructive surgery. It provides a brief history of tongue flaps dating back to 1909. Various types of tongue flaps are described, including posterior based dorsal flaps, anterior based dorsal flaps, transverse dorsal tongue flaps, perimeter flaps, and dorsoventral flaps. Indications for tongue flaps include moderate sized oral defects, defects exposing bone, and repairs after cancer resections. Four case studies are presented demonstrating the use of different tongue flap techniques for reconstructing posterior palatal, maxillary, and anterior palatal defects. Tongue flaps are concluded to be a reliable and versatile option for oral reconstruction with over 100 years of successful use and minimal
- The document discusses clinical aspects of cleft lip repair, including epidemiology, embryology, surgical anatomy, classification, management, and future directions.
- Cleft lip is the most common craniofacial malformation, occurring in about 1 in 1,000 live births. The rotation-advancement technique developed by Millard is currently the most commonly used repair method.
- The goals of cleft lip repair are to reconstitute lip competence and symmetry while minimizing scar visibility. Proper postoperative care and follow-up are important to monitor for complications and ensure good healing. Fetal surgery and in utero repair may be future areas of development.
This document discusses algorithms for reconstructing mandibular defects. It begins by classifying mandibular defects according to the AOCMF, Jewer's HCL, and Peter G. Cordeiro systems. Cordeiro's classification addresses both bony and soft tissue defects. The document then outlines algorithms for approaching reconstruction of different defect types, such as anterior, hemimandibular, and lateral defects. A variety of reconstruction options are discussed, including fibula flaps, scapular flaps, and regional flaps. Factors to consider like donor site morbidity and technical complexity are also addressed. The conclusion recommends the vascularized free fibula flap as the gold standard for large mandibular defects.
Chinese physicians were the first to describe cleft lip repair techniques, which initially involved simply excising the cleft margins and suturing them together. Over time, surgical techniques evolved to use local flaps. In the mid-20th century, the triangular flap technique was introduced and popularized as it allowed for tension-free repair of wide clefts. The rotation-advancement technique, described by Millard, is now most commonly used in the US as it is flexible and allows modifications during surgery while approximating a new philtral column. The goals of repair include reconstituting oral competence and symmetry while optimizing nasal function and aesthetics.
The Weber-Fergusson incision is indicated for access to tumors involving the maxilla extending superiorly to the infraorbital nerve and into or involving the orbit. It provides wide access to all areas of the maxilla. The incision line is drawn through the vermillion border along the filtrum of the lip, extending around the base of the nose along the facial nasal groove. It then extends infraorbitally below the cilium to the lateral canthus. Tarsorrhaphy sutures are placed in the eyelid. The incision is made through the skin and subcutaneous tissue along the nose, and the full thickness upper lip is transsected with ligation of the labial artery
This document provides an overview of surgical approaches to the temporomandibular joint (TMJ). It discusses several extraoral and intraoral approaches, including the preauricular, endaural, postauricular, coronal, retromandibular, and intraoral vestibular approaches. For each approach, it highlights considerations for exposure and visibility of the joint, avoidance of neurovascular structures, and postoperative aesthetics. Complications are also briefly mentioned. Detailed anatomical descriptions and illustrations are provided to demonstrate the surgical planning and exposure for different approaches.
This document discusses various surgical approaches to the temporomandibular joint (TMJ). It begins by outlining important anatomical structures in the region, including nerves, arteries and layers of fascia. It then describes several common approaches - preauricular, endaural, postauricular, submandibular, retromandibular and intraoral. For each approach, it provides details on the surgical technique, indications, advantages and disadvantages. References are also provided at the end for further reading on the surgical anatomy of the cervical and mandibular distributions of the facial nerve.
The nasolabial flap is used to reconstruct defects of the nose, lower eyelid, cheek, lip, oral commissure and anterior oral cavity. It has a reliable blood supply from the facial and angular arteries. The flap can be raised in a superior or inferior direction and is outlined along the nasolabial fold. The technique involves raising the flap in a supra-muscular plane and transferring it to the defect site through a transoral tunnel. Advantages are a concealed donor site scar and good color and texture match. Complications include infection, necrosis and asymmetry.
This document provides a 3-part summary of cleft lip and palate repair techniques. It discusses various techniques for unilateral and bilateral cleft lip repair such as Millard's rotation-advancement and Tennison-Randall triangular flap. For cleft palate repair, it describes techniques including Bardach two-flap palatoplasty and Furlow palatoplasty. It also covers topics like velopharyngeal insufficiency, alveolar bone grafting, and the roles of pre- and post-surgical orthodontics.
orthognathic surgery is very intresting and well knowing branch in oral surgery ....this presentation is dealing with jaw correction surgery in upper jaw.
Detailed discussion on diagnosis and management of TMJ ankylosis. Surgical anatomy and applied aspects of TMJ is discussed. Reconstruction of ramus-condyle unit is also discussed. Compications of TMJ surgery are also discussed
Panfacial fractures involve multiple facial bones, including the frontal bones, zygomaticomaxillary complex, naso-orbitoethmoid region, maxilla and mandible. Due to the complex nature of these injuries, management requires careful planning and sequencing of treatment to restore facial functions, features and symmetry. Key goals are to reestablish occlusion, stabilize major facial supports to restore three-dimensional contour, and provide a stable scaffold for soft tissue healing. Proper imaging, surgical approaches and attention to anatomical landmarks are important to achieve accurate reduction and fixation.
This document provides an overview of cleft lip and palate disorders including embryology, classification, incidence, clinical presentation, treatment approaches, and secondary management considerations. It discusses the development of the lip and palate, classifications of cleft types, incidence rates, clinical issues such as feeding and speech difficulties, and surgical techniques for cleft lip repair and cleft palate repair in infants and children. Secondary procedures for dental, hearing, nasal, and orthognathic issues are also outlined.
- Cleft lip and palate is a birth defect where the lip and/or palate do not fully form during development in utero.
- The incidence of cleft lip and palate varies by race, with Asians having the highest rate at 1 in 500 live births. Males are more likely than females to be affected.
- Treatment involves a multidisciplinary approach including surgery to repair the cleft, orthodontics, speech therapy and psychological support. The goal is to achieve normal appearance, speech and dental function.
Cleft lip and palate is a birth defect where the tissue of the mouth and palate do not properly fuse together, leaving an opening in the lip and/or roof of the mouth. It affects 1 in 750 births and can cause problems with feeding, speech, dental issues, and facial growth. The document discusses the anatomy, development, causes, classification, and management of cleft lip and palate. Management involves a multi-disciplinary team and stages of surgery to repair the lip, palate, and other issues, as well as other treatments like dental appliances and bone grafts.
Surgical management cleft lip and palateNikitha Sree
1) Surgical management of cleft lip and palate is a multidisciplinary approach involving multiple procedures from infancy to adulthood. These include lip repair between 4-6 weeks, palate repair between 12-18 months, alveolar bone grafting at 8-11 years, and orthognathic surgery in late adolescence.
2) Clefts can involve the lip, alveolus, hard and soft palate, and result from failure of fusion between embryonic processes. Classification systems describe the anatomical extent and location of the cleft.
3) Treatment aims to restore form and function, including feeding, speech, dental alignment and facial growth. Key procedures are lip repair to close
This document discusses the frenum attachment in the oral cavity, its development and variations. It describes different types of frenum attachments and associated syndromes like Ehlers-Danlos syndrome. Complications of an abnormal frenum like gingival recession and difficulty brushing are mentioned. Treatment techniques for abnormal frenum like frenectomy and frenotomy using conventional, Z-plasty, and laser methods are summarized. Post-operative instructions are provided.
This document provides an overview of cleft lip and palate defects, including their embryology, classification, incidence, and reconstruction. It discusses how clefts occur due to failures in fusion during embryonic development of the lip and palate. Common defects seen in cleft patients are also outlined. The reconstruction of cleft lip and palate is described in stages, including presurgical orthopedics, unilateral and bilateral lip repair techniques, various palatoplasty approaches such as the Bardach and Furlow methods, and bone grafting to reconstruct alveolar defects.
This document provides information on cleft lip and palate including etiology, embryology, classification, management, and alveolar bone grafting. It discusses that clefts result from problems during embryonic development in the first trimester. The classification system and various surgical techniques for repairing cleft lip and palate are described. Alveolar bone grafting is explained as a procedure to close the osseous cleft and provide support for dental arch development and eruption. The timing of primary versus secondary bone grafting is outlined.
This case report describes the use of tongue flaps to close anterior palatal fistulas in several patients with a history of cleft lip and palate surgery. Anteriorly based tongue flaps were used to close fistulas ranging in size. The tongue flap procedure involves elevating a portion of the dorsal tongue and closing the donor site, then using the tongue flap to cover the palatal defect. Patients recovered well with no speech or swallowing issues. The report concludes that the tongue flap is a reliable option for closing complicated palatal fistulas due to the tongue's good blood supply and ability to provide ample tissue.
Obturators for acquired maxillary defectsPriya Gupta
This document provides an overview of obturators for acquired maxillary defects. It discusses the historical development of obturators, objectives and ideal requirements, materials used for fabrication, classifications based on origin of defect and location, indications and functions. It also covers design considerations for support, retention and stability. Obturators are prosthetic devices used to close acquired openings of the hard palate and/or soft palate following surgery or trauma. They aim to restore esthetics and function like speech, swallowing and mastication.
18.Rahul VC Tiwari et al. Single layer anteriorly based tongue flap for extensive palatal cleft- a case report. - Innovative Publications - Journal of Oral Medicine, Oral Surgery, Oral Pathology and Oral Radiology. April-June 2018;4(2):118-120
1. The document describes the surgical repair of a large palatal fistula in a 7-year-old girl using an anteriorly based tongue flap.
2. An anteriorly based tongue flap was designed to match the size of the roughly quadrangular shaped palatal fistula measuring approximately 3 cm on each side.
3. The tongue flap was sutured to the edges of the defect and the donor site was closed. Follow up revealed no nasal regurgitation and mild speech improvement without complications.
This document discusses cleft lip and palate, including the embryology, causes, problems individuals may experience, and treatment approaches. It notes that clefts occur due to failure of fusion during embryonic development. Individuals with clefts often experience dental issues, malocclusion, speech difficulties, and ear problems. Treatment is multi-disciplinary and involves surgical procedures like cheilorrhaphy to repair the lip and palatorrhaphy to repair the hard and soft palate, as well as alveolar bone grafts and dental treatments throughout development. The goal is to correct anatomical issues and produce normal function and appearance.
This document discusses cleft lip and cleft palate, including the types, classification, embryology, anatomy, epidemiology, genetics, environmental factors, management, and associated syndromes. It provides details on the evaluation and surgical techniques for repairing cleft lip and cleft palate, including goals of surgery and common complications. Associated issues like airway management, hearing loss, and speech are also summarized.
1) Cleft lip and palate are among the most common congenital anomalies, resulting from failures of fusion during facial development in utero.
2) Clefts can involve the lip, palate, or both and have varying presentations from incomplete to complete.
3) Reconstruction is performed using standardized surgical techniques like Millard's procedure and involves a multidisciplinary team to address issues like feeding, hearing, speech, and dentition.
4) Post-operative management focuses on careful feeding and scar maturation, with long term goals of normal appearance, speech, and facial growth.
This document provides information on cleft lip and palate, including definitions, classifications, embryology, problems, and management. It defines cleft lip and palate as an abnormal separation in oral-facial tissue that occurs due to incomplete formation during fetal development. Treatment requires a multidisciplinary approach from prenatal diagnosis through adulthood and aims to address functional, aesthetic, and developmental issues through procedures such as cheilorrhaphy, palatorrhaphy, and alveolar bone grafting. Successful management of cleft lip and palate patients presents ongoing challenges due to the variety of impairments and extended treatment time required.
The document provides information on cleft lip and cleft palate including definitions, incidence rates, development, classifications, problems associated, and treatment protocols. It defines cleft lip as an opening in the upper lip and cleft palate as an opening in the roof of the mouth. Treatment is a multidisciplinary approach involving surgery to repair the cleft, orthodontics to align teeth and jaws, and speech therapy. Management occurs over many years from infancy through adulthood to address dental, esthetic, speech and other issues.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
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2. Introduction
• A cleft is a birth defect that occurs wh
en the tissues of the lip and palate of
the fetus do not fuse in pregnancy
• Cleft is derived from German word
“Kluft” which means a fissure/ cleave
• Cleft lip and palate are the second
most common congenital deformity
(after clubfoot).
• Earlier cleft lip known as hare lip
20. THEORIES OF CLEFT
LIP AND PALATE
• Failure of fusion of process
• Mesodermal migration
theory.
• The merging of prominences
• Other theories
21. 1. FAILURE OF FUSION
THEORY
• Separate processes fuse
to form central face- first
advanced by Meckel in
1808
• Popularized by Dursy
(1869) & Wilhelm His of
Leipzig University
(1901)
22. 2.MIGRATION OF MESODERM
THEORY
• Fleischmann of Erlangen,
Germany (1910).
• Veau (1934)- by penetration of
mesoderm across groove, normal
development was ensued while
failure of mesodermal migration
eventually led to breakdown &
cleft formation.
• Mesoderm gives rise to the
fibromusculae layer of the lip.
23. • Bulging effect - “hills” &
“valleys”
• Failure of sufficient mesoderm
to migrate - persistence of
groove established cleft
MIGRATION OF MESODERM THEORY
24. 3. THE MERGING OF
PROMINENCES
• Bradley M Patten - medial side of
cleft there is small portion of
prolabium
• Patten also noted- when cleft of lip is
relatively small - striking asymmetry
in configuration of nose.
• disturbance of potentialities of
mesenchyme of nasal processes.
25. • Steininger(1939) proposed the theory of rupture of
previously formed cysts in the soft tissue bridges.
• Pfeifer (1966) proposed the possibility that clefts were
formed not by failure of fusion but by the breakdown of lip
once intact.
OTHER THEORIES
28. VEAU (1931):
In 1931, Victor Veau
published his landmark
Division Palatine, which
described his approach
to evaluation and
management of cleft
palate.
31. Sub mucous
cleft
A palpable notch on the posterior
border of the hard palate
Bifd uvula- this may extend from a
mere groove on the uvula to
complete bifdity.
Zona pellucida or a bluish tinge in
the midline of the soft palate due
the paucity of muscle bulk at this
level.
32. Article: Prevalence of Dental Anomalies in a Population of Cleft Lip and Palate Patients
Dental Nasal
Feeding Skeletal
Ear problems Speech
34. Skeletal changes
Maxillary retrognathism in a patient with unilateral cleft lip and palate exhibits
increasing severity with age. A, At 10 years of age; B, 16 years; and C, 21 years.
Facial Growth and Development in Individuals With Clefts
John Daskalogiannakis, Gregory S. Antonarakis
35. Early profile convexity caused by protrusion of the premaxilla in
a patient with bilateral cleft lip and palate gradually turns into a
progressively worsening concave profile with age. A, At 5 years
of age; B, 11 years; and C, 18 years.
37. Precautions
• Do not flood the pharynx-
provokes aspiration
• Infant with a major cleft
swallows air while feeding-
feed more frequently than
normal child.
• Supplements required after
two weeks of breast feeding
38.
39.
40. Presurgical orthopedics:
Objectives :
To reduce the severity of the original
cleft deformity.
To eliminate surgical columella
reconstruction and reduce the resultant
scar tissue in bilateral cleft lip and
palate.
To improve the surgical outcome of the
primary repair in cleft lip and palate
patients.
41.
42. Timing of repair millard
Rule of 10
• Wt - > 10 pounds
• Hb - > 10 grams
• Age - > 10 weeks
• Initially – 3months of age
• Later
• Incomplete lip – 3 – 6 months
• Lip adhesion – 3weeks
• Definitive closure 6 – 8 months
• Soft and hard palate – 1 1⁄2 - 2 1⁄2 year with soft palate repair. For
the lip and nose repair, he waited for the incisors to erupt in order to
avoid the inversion that frequently takes place if the operation is
carried out before.
44. Objectives of the Cleft Palate Repair
• To produce anatomical closure of the
defect.
• To create an apparatus for development
and production of normal speech.
• To minimize the maxillary growth
disturbances.
45. Principles of
Palatoplasty
• Closure of the defect.
• Repositioning of the abnormal position of
the muscles of the soft palate.
• Reconstruction of the muscle sling.
• Favorable retro positioning of the soft
palate and uvula so as to achieve
velopharyngeal closure during speech.
• Last and most important is tension-free
suturing
46. Surgical
techniques
Von Langenbeck's bipedicle flap technique
Veau-Wardill-Kilner Pushback technique
Bardach's two-flap technique
Furlow Double opposing Z-Plasty
Two-stage palatal repair
Hole in one repair
Raw area free palatoplasty
Alveolar extension palatoplasty (AEP)
Intravelar veloplasty
Vomer flap
Buccal myomucosal flap
47. possibly the oldest palatoplasty
still widely used today
Commonly used for an incomplete
cleft of the secondary palate
without the presence of a cleft lip
and alveolus.
Von langenbeck
49. Ø Advantage:-
Easy to perform.
Requires less dissection.
Results in decreased raw area of palate.
Ø Disadvantages:-
Cannot be used in wider and complete
clefts.
Failure to provide additional palatal length.
Palatoplasty : Evolution and controversies Chang Gung medical journal
31(4):335-45·Nov 2007.
52. Cleft Palate Repair: Veau-Wardill-Kilner
Technique – Pushback Palatoplasty
Adversely affects midfacial growth in cleft
palate patients because of scar tissue anteriorly.
Higher rate of fistula in complete cleft palate than other techniques
because it provides only a single nasal mucosa layer anteriorly
Agrawal K. Cleft palate repair and variations. Indian Journal of Plastic
Surgery : Official
Publication of the Association of Plastic Surgeons of India.
Advantages:-
Lengthening the palate and repositioning
the levator muscle in a more favourable
position.
58. Cleft Palate Repair: Bardach
Ø The design of this flap is entirely dependent on the greater palatine
neurovascular pedicle and it provides greater versatility to cover the
cleft.
Advantages:-
Complete closure of the entire palate in one stage.
Creation of more physiologic soft palate muscle sling and a
layered closure technique.
Disadvantages:-
Does not provide additional length to the repaired palate to allow
normal speech production.
Bardach J. Two flap palatoplasty Bardach Technique. Operative Techniques in
Plastic and Reconstructive
61. Cleft Palate Repair: Furlow
Ø Advantages:-
No need to raise large mucoperiosteal flaps
from the hard palate.
The soft palate can be lengthened.[Good
speech outcome]
Ø Disadvantages:-
Non anatomical palatal
closure
Ignores musculus uvulae
Difficult to close wider clefts
Large raw area - needs to be
covered with buccal flap.
Palatoplasty : Evolution and controversies Chang Gung medical journal 31(4):335-
45· Nov 2007.
64. Early complications:
• Bleeding: Bleeding probably occurs
most commonly from the lateral
releasing incisions or from the
margins of elevated flaps. Hemostasis
needs to be meticulous.
• Airway: Closure of the palate may
compromise the airway,
65. • Dehiscence: Dehiscence of the repair is
probably usually the result of either
infection or hematoma, or closure under
excess tension. Partial dehiscence results
in fistula formation.
• In the Wardill-Kilner pushback technique,
these often occur at the junction of the
flaps in the hard palate and are very
difficult to close. In other repairs, they
most commonly occur at the junction of
the hard and soft palate. They can be
minimized by the avoidance of hematoma
and by avoiding undue tension.
Intermediate
Complications
67. Hardwicke et al Fistula incidence after primarycleft palate repair: a
systematic review of the literature. Plast Reconstr Surg 2014.
In 2014, meta-analysis reported that oronasal
fistulae occur in 8.6% of patients after cleft
palate repair based on 9294 patients from 44
studies.
2014
In 2015, systematic review of
2505 patients over a 2-year
period reported the
incidence of fistulae as 4.9%.
2015
68. Bykowski MR et al: The rate of oronasal fistula following
primary cleft palate surgery: a meta-analysis. Cleft Palate
Craniofac J 2015.
69. management of palatal fistula
Murthy J. Descriptive study of management of palatal fistula in one hundred and ninety-four cleft individuals.
Indian J Plast Surg. 2011 Jan;44(1):41-6. doi: 10.4103/0970-0358.81447.
74. VPI
Velopharyngeal insufficiency:
inability to achieve complete
closure of the velopharyngeal
apparatus during speech.
[Structural Defect]
Velopharyngeal incompetence:
Imperfect closure of
velopharyngeal apparatus that is
caused by neuromuscular
dysfunction. i;e impaired motor
programming of velopharynx.
[Neurogenic Defect]
Velopharyngeal inadequacy:
Imperfect closure of the
velopharyngeal apparatuscaused
by the tissue defect. [Tissue
insufficiency]
79. Classification of IVV
proposed by
Andrades et al
Type 0: No muscle dissection
or suturing of muscle
Type 1: No dissection,
parallel suturing of muscle
Type II a: Partial dissection
(release from posterior
palatal shelf but minimal
dissection from nasal and
oral mucosa) creating
inverted-U muscle sling
Type II b: Partial dissection
(dissection from nasal
mucosa but not oral mucosa)
creating inverted-V muscle
sling
Type III: Complete dissection
creating a transverse muscle
sling (radical IVV)
I b: Partial dissection
(dissection from nasal
mucosa but not oral mucosa)
creating inverted-V muscle
sling
Type III: Complete dissection
creating a transverse muscle
sling (radical IVV)
83. Conclusion
• Cleft palate repair has undergone major changes in the past
quarter century, the increased application of methods that
incorporate reconstruction of the levator palatine muscles has
produced much more predictable speech results.
84. References:
• Maxillofacial surgery - Peter Ward Booth, 2nd Edition, Vol. II
• Fonseca Oral and maxillofacial surgery - 2nd Edition, Vol. III
• Textbook of oral and maxillofacial surgery for clinicians
• Text book of Plastic surgery- Joseph Mc. Carthy – Vol. IV
• Perterson’s principles of Oral and maxillofacial surgery -
3rdEdition, Vol. II
• Janusz Bardach. Two flap palatoplasty- Bardach’s technique.
Operative techniques in plastic and reconstructive
surgery,1995;2(4):211-14.
85. Ask not for a spatula and torch to check your cleft
palate repair, but listen to your patient speak.- Dr.
Kilner
Thank you!
Editor's Notes
Isolated cleft palate occurs most commonly in females than in males
1/700 live births – with wide variability across geographic regions]
Orientals , Caucasians, blacks
The external human face develops between the 4th and 6th week of embryonic development. The development of the face is completed by the 6th week.
Between the 6th and 8th week, the palate begins to develop. Consequently, this causes a distinction between the nasal and oral cavities. This development is completed by the 12th week.
Frrontonasal , medial , lateral, max , mand processes
primary , SECONDARY PALTE
As the nose forms, the fusion of the medial nasal prominence with its contralateral counterpart creates the intermaxillary segment – which forms the primary palate (becomes the anterior 1/3 of the definitive palate). The intermaxillary segment also contributes to the labial component of the philtrum and the upper four incisors.
The maxillary prominences expand medially to give rise to the palatal shelves. These continue to advance medially, fusing superior to the tongue. Simultaneously, the developing mandible expands to increase the size of the oral cavity; this allows the tongue to drop out of the way of the growing palatal shelves. The palatal shelves then fuse with each other in the horizontal plane, and the nasal septum in the vertical plane, forming the secondary palate.
the palate is a bony/muscular partition that forms the roof of the oral cavity and the floor of the nasal cavities. It consists of two main parts; the hard palate and soft palate. The hard palate is the anterior bony portion, while the soft palate is the posterior muscular part.
It comprises the anterior two-thirds of the palate. The hard palate is formed by the fusion of two pairs of facial bones in the midline, the maxillae (upper jaw bones) and palatine bones. The palatine processes of the maxillae form the anterior three-quarters of the hard palate, while the horizontal plates of the palatine bones form the remaining posterior oneIncisive fossa, greater and lesser palatine foramina.
-quarter.
BLOOD VESSEL LIES IN THE PLANE OF GLANDULAR TISSUE
HARD PALATE –THIS PLANE SITUATED BETWEEN MUCOSA AND PERIOSTEUM
SOFT PALATE-THIS PLANE SITUATED BETWEEN MUCOSA AND MUSCLE
The oral aspect of the hard palate is covered by oral mucosa that is firmly bound to the underlying bone and overlies the mucus-secreting palatine glands and neurovascular structures. The nasal aspect on the other hand is covered by respiratory mucosa.
GREATER PALATINE ARTERY SUPPLIES HARDPALATE
LESSER PALATINE ARTERY -ANTERIOR SURFACE OF SOFT PALATE
ASCENDINGPALATINE-BRANCH OF FACIAL ARTERY AND ASCENDING PHARYNGEAL ARTERY – SUPPLIES SOFT PALATE
The soft palate (velum) is the posterior muscular portion of the palate that continues from the posterior border of the hard palate. It is a mobile soft tissue flap that curves posteriorly and inferiorly into the pharynx, demarcating the nasopharynx from the oropharynx. On its posterior free margin, the soft palate bears a conical projection in the midline known as the uvula. The epithelial lining of the oral surface of the soft palate contains a small number of taste buds.
Extrinsic muscles
Levator veli palatine
Tensor veli palatine
Palatoglossus
Palatopharyngeus
Intrinsic muscle
Musculus uvulae
Originates from the scaphoid fossa at the base of the medial pterygoid plate, spina angularis of the sphenoid and from the cartilaginous part of the auditory tube
he muscle descends anteroinferiorly and winds around the pterygoid hamulus, to which some fbers are attached, and passes into a tendon that fans out to form the palatine aponeurosis few fbers are attached to the maxillary tuberosity, the palatine aponeurosis
The main role of the tensor is to dilate the Eustachian tube and its role in speechIn a cleft palate child is defcient, especially medially is insignificant
In a cleft palate child, the palatine aponeurosis is defcient, especially medially
Arises from the petrous
The muscle descends on either side, enters the intermediate 40% of the soft palate, and forms a muscular sling with its counterpart on the other sidepart of the temporal bone and from the cartilaginous part of the Eustachian tube
When the paired muscle contracts, it elevates the soft palate superiorly and posteriorly to enable closure of the velopharyngeal sphincter. The latter is formed by the soft palate anteriorly, the posterior pillars of the fauces on either
In the normal palate, the levator forms a muscular sling that suspends the soft palate from the cranial base.
Running from its origins at the cranial base to its insertion into its partner in the velum, the levator takes a downward, forward, and medial course that facilitates a cranial, posterior, and lateral pull on the soft palate during velopharyngeal closure.3 a cleft child, as there is obviously no continuity across the midline due to the cleft, there are abnormal attachments of the levator muscle to the palatopharyngeus muscle posteriorly, to the edge of the cleft medially, to the tensor veli palatini, and to the posterior edge of the hard palate anteriorlyside, and the posterior pharyngeal wall posteriorl
This clefted configuration prevents the levator, the principal motor of the velar component of velopharyngeal closure, from exerting its upward, backward, and lateral pull. Moreover, in the cleft palate, the levator has 3 abnormal associations that must be addressed in repairing the defect: an insertion onto the posterior medial edge of the hard palate, associations with the aponeurosis of the tensor veli palatini, and lateral adhesions to the superior pharyngeal constrictor
Has a palatine portion, a pterygopalatine portion and the salpingopharyngeal part. It arises from the lateral and posterior part of pharynx and attaches into the velum. Its superior fbers arise from complex intermingling with the superior constrictor muscle
It is found in the posterior pillar of the fauces. The fbers pass horizontally into the posterior three fourths of the soft palate inferior to the fbers of the levator palatini muscle
The muscle helps to narrow the velopharyngeal opening by bringing the palatopharyngeal arches together
he muscle is relatively well developed in the cleft palate child and ends partly along the cleft edge and partly along the posterior edge of the hard palate. Some fbers pass along the edge of the cleft along with the levator to form the muscle of veau
Arises from the posterior nasal spine and the palatine aponeurosis, inserts into the junction of the proximal and middle thirds of the uvula.
he presence and extent of the muscle in a cleft palate child is disputed. It is also supposed to be absent in occult submucous cleft patients
arises from the tongue
inserts into the soft palate The paired muscle forms the anterior part of the sphincter and narrows the isthmus.
It is antagonistic to the levator in its action, drawing the palate inferiorly This muscle doesn’t play a major role in cleft palate
Nerve supply
The theory that separate processes fuse to form the central face Was first advanced by meckel in 1808 and later supported by Baer in 1868, german anatomist dursy in 1869 and german biologist Wilhelm his of leipzig university in 1901 working on chick Embryos popularized the theory of embryological development Of the midface by the fusion of five facial processes around the Rim of the primitive oral cavity or stomodeum. superiorly there Is the frontonasal process laterally there are the paired maxillary Processes and inferiorly the paired mandibular processes. according to the classical theory all of these processes grow forward As fingerlike projections to fuse with each other to form the Normal face between the fifth and eighth weeks. the frontonasal Process gives rise to three processes the frontal nasomedial Globular and nasolateral responsible for the development of Nose prolabium and premaxilla. the maxillary process by fusing With the nasomedial process forms the lateral upper lip and Cheek. the mandibular processes meet to form the lower jaw, Chin and lower lip. this hypothesis reigned some 30 years as the accepted basis of facial formation. the failure of fusion of These processes seemed to explain the formation of the various Degrees of unilateral and bilateral clefts and even the rare midline Upper and lower lip cleft. Thomas mullen of san francisco in 1931 following the Dursyhis hypothesis described it this way, Embryologically the growth toward the median line of the processes going Into the formation of the mouth and lips progresses until in the seventh Week , the manner in which the processes unite is similar To the healing of wounds the ectodermic coverings of the processes unite And the mesodermic elements spread across the line of epithelial union To give rise to the muscles and connective tissue of the adult structure. Epithelial ingrowths separate the lips from the alveolar portion of the jaw.Thirty years later that is in 1961 pruzanskys book congenital Anomalies of the face and associated structures presented this Schematic design of the fusion hypothesis. The fusion theory is no longer in vogue the term process Implies fingerlike projection of tissue and fusion implies That the projections meet. their epithelial walls disappear and They then grow together as shown as early as 1910 by pohlmann.
Zoology professor Fleischmann of Erlangen, Germany in 1910 had hypothesis that cleft palate is the arrest of the disappearance of the epithelial membrane which remains intact or left unpenetrated by the adjacent mesoderm.
this mesodermal penetration theory appealed to Victor Veau who admitted that until 1930, at the age of 60 he had never even looked at an embryo. in 1934 Veau disenchanted with the old facial process theory which he now considered ‘myth’,
.
Thus Veau endorsed the theory that with the penetration of Mesoderm across the groove, normal development ensued while failure of the mesodermal migration eventually led to Breakdown and cleft formation. His acceptance of the importance of mesodermal penetration might however explain his enthusiasm for wire approximation of the muscles across the cleft
This theory proposes that with invagination of the oral cavity and nasal pits there is ‘heaping up’ of the adjacent tissue.
As oral and nasal cavities deepen there is increase in sizes of the prominences due to the penetration of mesoderm.
As more mesoderm enters, the bulging effect is increased thus transforming the wall of tissue with ectoderm on one side and endoderm on the other into “hills” and “valleys”
Failure of sufficient mesoderm to migrate into specific area would be responsible for the persistence of groove which leads to established cleft
Bradley M Patten - medial side of the cleft there is small portion of the prolabium that could have been derived from the nasomedial process.
He believed that it is the prime mover in this important union and that when its growth is inadequate cleft will remain.
Patten also noted that even when the cleft of the lip is relatively small there is striking asymmetry in the configuration of the nose.
This means that there is disturbance of the potentialities of the mesenchyme of the nasal processes.
GROUP I – PRE-ALVEOLAR CLEFTS
UNILATERAL , BILATERAL OR MEDIAN
GROUP II – POST-ALVEOLAR CLEFTS
SOFT PALATE ONLY
SOFT AND HARD PALATES
SUBMUCOUS CLEFT
GROUP III – ALVEOLAR CLEFTS
UNILATERAL BILATERAL OR MEDIAN
) Cleft of soft palate only.
2 ) Cleft of hard and soft palate extending no further than incisive foramen, thus involving secondary palate alone.
3) Complete unilateral cleft, extending from the uvula to the incisive foramen in the midline, then deviating to one side and usually extending
through alveolus at the position of the future lateral incisor tooth.
4) Complete bilateral cleft, resembling
Of note, while Veau discusses the most intricate of anatomical findings in Division Palatine, he purposefully chose to exclude ‘‘confounding’’ details (such as severity) from the classification system itself, preferring simple groupings. In his subsequent work dedicated to cleft lip, Bec-de-Lievres ` (Veau and Recamier, 1938), Veau eschews ´ taxonomical groupings altogether and instead advocates a clear and concise description of the labial defect (including laterality [unilateral/bilateral/median] and extent [simple/ total]). The minimalism, morphologic basis, and clinical relevance of Veau’s approach to classification made it very attractive to contemporary surgeons.g Group III with two clefts extending forwards from the incisive foramen through the alveolus
Kernahan and Stark proposed three groups: 1. Clefts of structures anterior to the incisive foramen 2. Clefts of structures posterior to the incisive foramen 3. Clefts affecting structures anterior and posterior to the incisive foramen
Occult submucous cleft palate is diagnosed by multiview videofluoroscopy and nasal endoscopy during workup for VPI.
Congenitally Missing teeth, Hypodontia, Hyperdontia, Oligodontia
Presence of natal and neonatal teeth
Anomalies of tooth morphology like microdontia, macrodontia
Poor periodontal support, early loss of teeth
An oral feeding should be completed within 20–30 minutes. Longer feedings may lead to a net caloric loss due to excessive energy output
Isolated cleft lip – feed quite well
Cleft palate – difficulty
Feeding by keeping baby at 45-60 degree angulations reduces risk of aspiration
Frequent burping –Aerophagia
Specialized nipples
Close attention to weight gain
In 24 hours…2 – 3 ounces of milk for each pound of weight
Intermittent episodes of breast feeding and specialized bottle feeding.
Tendsor opens the eustachian tube whilemeating, releases fliod’’due to defect , no drainage of ear fluids
Otitiis media
1689, Hoffmann demonstrated the use of facial binding to narrow the cleft and prevent postsurgical dehiscence.
A similar technique helps was used by Desault in 1790 to retract the maxilla before surgical repair in patients with bilateral cleft repair
The modern school of presurgical orthopaedic treatment in cleft lip and plate was started by McNeil in 1950- series of plates to mould the alveolar segments, populaprized by Burston, an orthodontist.
This technique closes the incomplete cleft of the hard and soft palates without lengthening the palate by mobilizing bipedicle mucoperiosteal flaps medially.
incision along the attached gingiva that runs posteriorly to a point lateral to the hamulus, approximately 1 cmposterior to the maxillary tuberosity. A mucosal incision along the border of the cleft, between the oral and nasal mucosa, marks the flap’s medial extent. Nasal mucosa flaps are sutured to one another in the midline to repair the nasal lining defect (often incorporating a vomer flap). The bipedicled hard palate flaps are advanced to close the oral side of the defect.
Closure is done with a 4–0 Vicryl starting with the nasal layer in a simple interrupted fashion, incorporating vomer flaps anteriorly. The apex of the uvula is closed with a single horizontal mattress suture. Next, the intravelar veloplasty is completed. Interrupted or horizontal mattress sutures are used to reorient the levator veli palatini along the posterior velum to create the levator sling. Oral closure is then done with simple interrupted sutures using a 4–0 Vicryl working posteriorly to anteriorly. Finally, the relaxing incisions are stabilized with interrupted sutures through the medial gingival edge and microfibrillar collagen hemostatic agent is placed in the open defects laterally.
Ø The Von Langenbeck technique is similar to Bardach palatoplasty but preserves an anterior pedicle for increased blood supply to the flaps.
Ø Used in isolated cleft palates.
Derived from a modification of the von Langenbeck technique
Velopharyngeal incompetence is relatively common following palatoplasty either because there is insufficient mobility of the soft palate or because the length of the repaired palate is inadequate to reach the posterior pharyngeal wall. To increase the anteroposterior length of the palate at the time of primary palatoplasty, various mucoperiosteal flap maneuvers in the hard palate have been described in the literature.
* It can be used to increase the palatal length. The Veau-Wardill-Kilner pushback palatoplasty can be suitably used for incomplete clefts of the hard palate. The flap design is similar to the von Langenbeck palatoplasty. The essence of this technique is the V to Y incision and closure on the hard palate (Fig. 2). The pushback technique has the advantage of lengthening the palate and repositioning the levator muscle in a more favorable position. However, this modification involves extensive dissection. At the free anterior end, the mucoperiosteal flaps can then be approximated directly or in a V-Y closure to lengthen the soft palate.
Bardach- intiatily anteriorly onlyLate* The more extensive two-flap palatoplasty is a modification of the Langenbeck technique, extending the relaxing incisions along the alveolar margins to the edge of the cleft. This designs flaps entirely dependent on the circulation from the
palatine vessels but also much more versatile in terms of their
placement.. Intravelar veloplasty is an essential part of this closure
In a complete unilateral cleft, the mucoperiosteal flap from the medial segment can be shifted across the cleft and closed directly behind the alveolar margin. The fistula in the anterior hard palate can be virtually eliminated by this technique.(22) Two-flap palatoplasty also has a minimal effect on subsequent maxillofacial growth due to the limited area of bone denudation on the hard palate when the mucoperiosteal flaps are elevated.(23,24) The limitation of this technique is that it does not provide additional length to the repaired palate to allow normal speech production. A variation from the standard technique of twoflap palatoplasty has been reported using supraperiosteal flaps instead of the mucoperiosteal technique for palatal closure.(25) Although this new approach improves speech outcome, it still requires further evaluation in a larger series to ascertain its applications.
George Dorrance (1877–1949) of Philadelphia realized that a
distinct number of patients with cleft would develop velopharyngeal
dysfunction caused by inability of the soft palate to
touch the posterior pharyngeal wall. In fact, he advocated
muscle transposition but did so by fracturing the hamulus,
which he believed would change the vector of muscle contraction
and in combination with techniques of Langenbeck
would lengthen the palate.
The technique is based on the concept of lengthening the soft palate by use of “Double-opposing Z-plasties.”.” This involves mirror-image Z-plasties to the oral and nasal layers while also retropositioning and reconstructing the levator muscle mechanism by keeping the levator palatini muscle on each side attached to the limb of the Z-plasty that moves posteriorly (FIG 1).1
Randall has described a variation for wider CP that involves using Langenbeck-type lateral releasing incisions to relieve the tension on the oral Z-plasty
BV
Alternating the reversing Z-plasties of the nasal and oral flaps and repositioning the levator veli palatine muscle within the posteriorly mobilized flaps.
Ø Effective for primary closure of a submucous cleft palate and secondary correction of marginal velopharyngeal insufficiency.
In a bilateral complete cleft palate, a midline incision along the free margin of vomer is required to create two septal-mucosal flaps in opposite directions. These two flaps are used to bridge the gap between the free edges of the nasal mucosa. The two-flap palatoplasty combined with a vomer flap results in a four-flap palatoplasty that can be applied for simultaneous closure of the nasal and oral defects in the cleft palate. This technique results in a twolayer closure with a low fistula rate and less maxillary growth retardation. The long-term effect of this technique on facial growth is minimal
This flap has a high incidence of maxillary retrusion, presumably from injury from vomer-premaxillary sutures, and a high fistula rate
because of postoperative swelling
New airway mechanism
Cohen et al. [5] classified them according to their site as pre-alveolar, alveolar, post-alveolar, hard palate, hard-soft palate junction, soft palate and uvula. The commonest site for fistulae is the junction of the hard and soft palate.
Tension , infection ,
SOMERLAND PALATOPLASTY
Age of Surgery
• Hard Palate: 3 months
• Soft palate: 1 Year
Technique
• Hard Palate: Single layer vomer flap at the time of lip closure
• Soft Palate: Intravelar veloplasty
Ø Guerrero-Santos and Altamirano, were the first to report on the use o tongue flaps for palatal defect closure.The tongue flap is easy and reproducible with excellent esthetical
and functional results. Advantages: The advantages are th use of adjacent tissue, the excellen blood supply and the low morbidity idonor site.Ø Disadvantage: Inability in swallowing and speech until depedicling of the flap and in some cases the attachment of the flap can be lost due to traction.
BMMF is a vascular and dependable flap. Vascular supply of the flap is consistent and profuse.
Ø The buccinator myomucosal flap is effective in
reducing/eliminating hypernasality in patients with
cleft palate and velopharyngeal insufficiency.
Ø Advantages:
Flap congestion is occasional and necrosis is rare.
It tolerates stretching, folding, and twisting.
Ø Disadvantages:
Fibrosis. Secondary healing.
Parotid duct orifice injury.
Late Complications
• Maxillary retrusion: Cleft palate surgery in the developing
child is known to be associated with Hypolpastic maxilla
The decreased prominence of maxillary complex could be
caused mainly by the shortened maxillary length; meanwhile,
posterior position of the maxillary body may have
some influence on the maxillary protrusion
changes produced in the anatomy of the pharynx by closure.
This is particularly relevant in babies with Pierre Robin
sequence. Some surgeons use a temporary tunnel stitch,
which does allow immediate control of the tongue position
and potential improvement in the airway in the first postoperative
hours. The use of an optimally positioned nasopharyngeal
airway can be very helpful in the postoperative
period.
Inability to achieve complete closure of the velopharyngeal apparatus during speech.
Velopharyngeal apparatus (Regulation of airflow from the lungs and larynx)
Secondary Palatoplasty aims at correcting the velopharyngeal inadequacy (VPI)
VPI is defined as inadequate closure of the soft palate during speech to the posterior pharynx during speech, resulting in air leak up into the nasopharynx
(Lindsey and Davis, 1996).
5% to 36% of patients who have undergone primary palatoplasty have persisiting VPI
(Dorf and Curtin, 1982; Bardach and Morris, 1990; Peat et al., 1994; Hudson et al., 1995)
To improve the speech in children with cleft palate, primary pharyngeal flap pharyngoplasty is performed in a few center's
This procedure is not popular presently, as it unnecessarily subjects the patients to the disadvantages of pharyngeal flap surgery like sleep apnea, hypo nasality etc.
This creates an abnormal anatomy in all the cleft palate patients, which is not acceptable to most surgeons.[22] Since the majority of these patients will not develop velopharyngeal incompetence after classical palatoplasty, this procedure seems to be an overkill.
Dissection of the Levator Palati from the posterior border of the hard palate, nasal and oral mucosa and posterior repositioning.
Ø Suturing of the muscle with that of the opposite side for
the reconstruction of the Levator sling.
Sommerlad dissects the levator palatini belly separately and
sutures independently as the Levator is the dominant muscle for
elevation of the soft palate during speech. Also tensor tenotomy is performed.
Ø Court Cutting transects the Tensor Palati and to keep its function intact, the cut end is transfixed with the hook of the hamulus.
he lateral view shows the anatomy of the soft palate and provides information on the movement of the tongue, palate, and posterior pharyngeal wall as well as demonstrating any Passavant ridge (The lateral view cannot demonstrate movement of the lateralpharyngeal walls or the sphincteric movement of the velopharynx. Lateral pharyngeal walls can move incongruously with respect to the
This child has demonstrates very limited velopharyngeal (VP) closure which is significantly impacting speech intelligibility.